Intra-articular Methylene Blue Injection Technique

Updated: May 22, 2017
  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Erik D Schraga, MD  more...
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Technique

Approach Considerations

Intra-articular injection of dye requires the ability to create enough dye pressure to distend the joint capsule and maximize the chances of visualizing dye extravasation from the wound. An 18-gauge needle is the recommended gauge for injection or aspiration of most adult joints.

This is a painful procedure that involves distention of the joint capsule (much as in arthroscopy); therefore, both parenteral analgesia and local anesthesia are indicated. [7, 8]

Select a joint injection approach that is as far as possible from the skin wound. Make sure to avoid any neurovascular structures. Aspirate back as much fluid as possible before withdrawing the needle.

Intra-articular injection of methylene blue that demonstrates extravasation of dye from the wound site is highly suggestive of open joint injury. However, open joint injury may still be present in the absence of dye extravasation; therefore, an orthopedic consultation is recommended for all patients with a suspected open joint injury. Extravasation of contrast from an open joint injury necessitates immediate administration of intravenous (IV) antibiotics [9]  and emergency (≤6 hours) orthopedic evaluation for exploration and irrigation of the joint.

An alternative technique that can be used in patients who are allergic to methylene blue is injection of sterile fluorescein in normal saline (NS) solution into the joint space. [10, 11]  The authors recommend that the fluorescein-NS solution be tested for fluorescence with a Wood lamp before injection into the joint.

Next:

Injection of Methylene Blue Into Joint

Obtain informed consent from the patient.

On a sterile drape, open the sterile bowl, syringes, and needles. Pour the sterile NS solution into the sterile bowl, and add 1-2 mL of methylene blue to create a dark solution (see the image below). Fill at least one 20- or 30-mL syringe with the dark solution.

Adding methylene blue to normal saline solution. Adding methylene blue to normal saline solution.

After providing appropriate parenteral analgesia, cleanse a wide field by scrubbing the affected joint with a sterile preparation or a surgical scrub in circular motions, starting from within the wound and working outward (see the image below). Repeat the scrubbing process at least two more times. Cover the joint with sterile drapes to create a sterile field.

Skin preparation. Skin preparation.

Select a joint injection approach that is as far as possible from the skin wound (see the image below). Make sure to avoid any neurovascular structures.

Identify the injection site. Identify the injection site.

Elevate a skin wheal of local anesthetic using a 25-gauge needle (see the image below).

Skin wheal elevation. Skin wheal elevation.

Switch to a 21- or 18-gauge needle, and continue to inject lidocaine into the subcutaneous and deeper soft tissues until the joint space is entered (see the image below). Entry into the joint space can be confirmed by increased ease of injection and by aspiration of joint fluid (which is likely to appear bloody rather than its normal straw color).

Local anesthetic infiltration and entry into the j Local anesthetic infiltration and entry into the joint space.

Once the joint capsule is entered, secure the needle in the joint space with the nondominant hand while using the dominant hand to switch to the 20- to 30-mL syringe that contains the NS and dye solution (see the image below).

Switching syringes. Switching syringes.

Inject the solution into the joint until it is fully distended. (The volume required to distend a joint fully varies among different joints and patients.) Watch the wound site for contrast extravasation (see the image below).

Dye extravasation from an open knee injury. Dye extravasation from an open knee injury.

Aspirate back as much fluid as possible, and withdraw the needle.

Clean the skin and wound with remaining preparation solution, and apply a sterile dressing over the wound and injection site. Extravasation of contrast from an open joint injury calls for immediate administration of IV antibiotics and emergency orthopedic evaluation for exploration and irrigation of the joint.

The procedure is depicted in the video below.

Intra-articular methylene blue injection video clip.
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Complications

Potential complications of intra-articular injection of methylene blue include the following:

  • Infection - As with any other invasive procedure, infection may be introduced [9, 12] ; however, if infection occurs, introduction of infectious organisms is likely to have occurred via the open joint injury itself rather than via the injection
  • Bleeding or nerve injury - Proper technique and awareness of normal anatomy should minimize the chances of injuring a neurovascular structure
  • False-negative result from injection - Small open defects in a joint capsule or failure to inject enough dye into the joint to allow dye extravasation might lead to a false-negative intra-articular dye injection result; consultation with an orthopedic surgeon is recommended in all cases of suspected open joint injury
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